Male Pattern Baldness

Authored by , Reviewed by Dr Hannah Gronow on | Certified by The Information Standard

Male pattern baldness affects over half of men to some extent over the age of 50 and most men at some stage in their lives. Most affected men do not wish to have any treatment. If required, there are some treatments which can prevent further hair loss and may help hair regrow.

Male pattern baldness is the common type of hair loss that develops in most men at some stage. The condition is sometimes called androgenetic alopecia. It usually takes 15-25 years to go bald, but can be quicker.

Typically, at first the hair begins to thin (recede) at the sides (temples). At the same time, the hair usually becomes thin on the top of the head. A bald patch gradually develops in the middle of the scalp. The receding sides and the bald patch on the top (the crown) gradually enlarge and join together, leaving a patch at the front. The patch at the front eventually thins as well.

A rim of hair is often left around the back and sides of the scalp. In some men, this rim of hair also thins and goes, leaving a completely bald scalp.

Nearly all men have some hair loss by the time they are in their 60s. However, the age the hair loss starts is variable. About three in ten men aged 30 years and half of men aged 50 years have significant balding.

A similar condition affects women but in a different pattern. In women it tends to particularly affect the top of the head. It may also be a more general thinning of hair all over the head. Hair thinning in women is much more common after the menopause. Around a third of white Caucasian women in the UK have some hair loss once they reach the age of 70. You can read more about this in the separate article called Understanding female hair loss.

Hair is made in hair follicles which are like tiny pouches just under the skin surface. A hair normally grows from each follicle for about three years. It is then shed and a new hair grows from the follicle. This cycle of hair growth, shedding and new growth, goes on throughout life. The following is thought to occur in men as they gradually become bald:

  • Affected hair follicles on the scalp gradually become smaller than normal.
  • As the follicle shrinks, each new hair is thinner than the previous one.
  • Before falling out, each new hair grows for much less time than the normal three years or so.
  • Eventually, all that remains is a much smaller hair follicle and a thin stump of hair that does not grow out to the skin surface.

Male hormones are involved in causing these changes. The level of the main male hormone, testosterone, is normal in men with baldness. Cells in the skin of the scalp convert testosterone into another hormone called dihydrotestosterone. For reasons that are not clear, affected hair follicles become more sensitive to dihydrotestosterone, which causes the hair follicles to shrink. It is also not clear why different hair follicles are affected at different times to make the balding process gradual. It is also not clear why only scalp hairs are affected and not other areas such as the beard or armpits.

The condition usually runs in families. If your father lost his hair at a young age, unfortunately that probably means you will too. Various genes have been shown to be involved.

Understandably most men can feel less good about their appearance when they lose hair. This can sometimes affect their mood and well-being. Some counselling can help men come to terms with this natural process of ageing.

There is more risk of sunburn and sun-related skin damage when the skin is not protected by hair. This can be avoided by the use of suntan lotions and hats.

Women with male pattern baldness should be checked for causes of raised male hormone levels. For example, conditions such as polycystic ovary syndrome - a condition in which cysts develop in the ovaries. 

Coming to terms with losing one's hair is difficult for many men. Unfortunately there are plenty of private clinics out there who promise incredible results, but often don't warn you about what can go wrong. Hair replacement treatments are not always that effective and can rapidly become very expensive. Before you commit to anything, get a few opinions from different places. Preferably try to get the opinion of an impartial doctor in a state-funded health system, like the NHS.

No treatment

To become gradually bald is a normal part of the ageing process for most men. No treatment is wanted or needed by most affected men. Normal washing and combing of hair will not make it fall out any quicker, so continue with your normal hair routine.

It helps to find a style that suits you: many people opt for a short cropped style. Finding a good hairdresser or barber can make you look and feel a lot better.

For some men, baldness can be distressing, particularly if it is excessive or occurs early in life. Treatment may then help. 

Medication

Currently there are two medicines that help - finasteride and minoxidil. Neither is available on state-funded systems like the NHS, so you need to pay the full price for them.

Finasteride was launched in the UK in 2002, although it has been available in the USA since 1997. It works by blocking the conversion of testosterone to dihydrotestosterone. The hair follicles are then not affected by this hormone and can enlarge back to normal.

In around 1 in 3 to 6 men taking finasteride, enough hair regrowth occurs for them to consider treatment helpful.

Some points about finasteride include the following:

  • It takes about four months for any effect to be noticed and up to 1-2 years for full hair growth.
  • The balding process returns if treatment is stopped. Therefore, if successful, you need to carry on treatment to maintain the effect.
  • Side-effects are uncommon. The most common is that about 2 in 100 treated men report loss of sex drive (libido).
  • It does not work in women with male pattern baldness.
  • You need a private prescription to get it from a pharmacy.
  • You need to keeping taking it for it to work. Once you stop, the hair goes back to how it was.

Minoxidil lotion is a rub-on treatment that you can buy at pharmacies, without a prescription. It is not clear how it works. The higher-strength solution (5%) is for men only and is more effective than the 2% solution. The 5% strength is now also available as a foam.

There is debate as to how effective it is. It is most effective when used early on, rather than when a lot of hair has already been lost. It seems that it is best used to prevent further hair loss but some hair regrowth occurs in some users.

Some points about minoxidil include the following:

  • It needs to be rubbed on to the scalp every day.
  • It usually takes four months or more for any effect to be noticed.
  • Treatment needs to be continued indefinitely. Any new hair that does regrow falls out two months after treatment is stopped.
  • It is quite expensive.
  • It may work in some women who have male pattern baldness.
  • Side-effects are uncommon - for example, skin irritation or a rash sometimes occurs.

Wigs

A wig is the traditional option for baldness. Some people find them useful; others find them uncomfortable and not very convincing. For male pattern baldness, they cannot be prescribed on the NHS, so they may be expensive.

Scalp surgery

Techniques such as hair transplantation, scalp flaps and other procedures have been used for a number of years. Newer techniques are giving better results. Success rates vary. It is expensive and not available on the NHS. 

However, hair transplant surgery can sometimes go wrong. Although complications are rare, they can make your scalp look much worse. Sometimes for example, the blood supply to the scalp can become blocked, resulting in the skin dying off in the centre of the scalp, a situation called scalp necrosis:

Hair transplant scalp necrosis

Scalp necrosis

Image source: Open-i (Feily A et al) - see Further reading below 

And some techniques will leave a scar, from where the hair follicles were taken. The scar can be quite noticeable for a while after surgery:

Hair transplant scar on scalp

Hair transplant scar

Image source: Open-i (Dua A et al) - see Further reading below

So take your time before deciding to have hair transplant surgery and make sure you are fully aware of the pros and cons.

Further reading and references

  • Alopecia, androgenetic - male; NICE CKS, June 2016 (UK access only)

  • Alopecia, androgenetic - female; NICE CKS, May 2016 (UK access only)

  • Blume-Peytavi U, Blumeyer A, Tosti A, et al; S1 guideline for diagnostic evaluation in androgenetic alopecia in men, women and adolescents. British Association of Dermatologists 2011 164, pp5–15

  • Valente Duarte de Sousa IC, Tosti A; New investigational drugs for androgenetic alopecia. Expert Opin Investig Drugs. 2013 May22(5):573-89. doi: 10.1517/13543784.2013.784743. Epub 2013 Apr 4.

  • Mella JM, Perret MC, Manzotti M, et al; Efficacy and safety of finasteride therapy for androgenetic alopecia: a systematic review. Arch Dermatol. 2010 Oct146(10):1141-50. doi: 10.1001/archdermatol.2010.256.

  • Feily A, Moeineddin F; Feily's method as new mode of hair grafting in prevention of scalp necrosis even in dense hair transplantation. Dermatol Pract Concept. 2015 Jul 315(3):41-6. doi: 10.5826/dpc.0503a10. eCollection 2015 Jul.

  • Dua A, Dua K; Follicular unit extraction hair transplant. J Cutan Aesthet Surg. 2010 May3(2):76-81. doi: 10.4103/0974-2077.69015.

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